Examining Patient Engagement

In our April Intelligence Report, the top challenge cited by leaders for their primary care redesign efforts is to get patients engaged in their own care. HealthLeaders Media Council members discuss why this is so difficult, and what steps their organization is taking in this area.

This article first appeared in the November 2014 issue of HealthLeaders magazine.

Michael Schaffrinna, MD
Chief Medical Officer
Community Health of Central Washington
Yakima, WA

There are two pieces. One, patient engagement in their own health is challenged by provider use of the electronic health record, and second is the social determinants, such as financial resources and education, of the patient population.

We are a community health center, so the patients we care for tend to be more disadvantaged Medicare and Medicaid and indigent populations. We don't have necessarily the educational background or the fiscal resources to be able to engage in the way that people need. That would be the No. 1 barrier, just the social determinants. Otherwise, most people have access to smartphones and things like that, so using the portal to help them become more engaged in their healthcare is certainly available to the vast majority of folks.

The challenge there is providing information through our EHRs in a way that is easy to understand. Providers across the country are being forced to adapt to EHRs that are not necessarily making life easier for them. We adopted an EHR about two years ago now, and we are still trying to recover from that decision. It is like a road full of potholes, and we have to fill the potholes so that providers have more time to engage with the patients.

Sam J.W. Romeo, MD, MBA
CEO
Tower Health & Wellness Center
Turlock, CA

Patient engagement has always been a challenge, and typically the response is, people want to take a pill for a quick fix. Nobody wants to recognize that the majority of diabetes is based upon obesity and 75% of most of the chronic illnesses are based on lifestyle issues. That is the challenge. How do we adjust the lifestyle?

I don't think the medical profession has done a good job at all. I spent 25 years in academia, and I can assure you that the impact of the importance of wellness, prevention, and lifestyle issues is almost zero. There are economic pressures. You get paid for taking care of diseases, not people. And patient engagement requires that you begin to think about what motivates people. We are more than disease. We are body, mind, and spirit, and mind and spirit have been undervalued, underassessed, and undertreated. If you think about those two components that is oftentimes what defines the negative effects that impact the body.

The economic incentives are beginning to change, which is a positive. People taking care of people instead of disease, where providers can effectively become more involved with the care of patients with prevention, wellness and lifestyle issues are a positive direction. High-deductible health plans increases the responsibilities of people making decisions on their own and wellness and prevention as a priority, and that is an important piece.

Tricia Nguyen, MD
President
Texas Health Population Health, Education & Innovation Center
Arlington, TX

On the challenges of engagement: Healthcare is not as simple, especially if you are a patient with multiple comorbidities. That requires more knowledge and more things to do, and a lot of it relates to lifestyle modification, and it is hard to change behaviors. We are creatures of reactivity, and if you are not experiencing pain, you aren't going to do anything about it. But even then, if the medication controls their symptoms, they may feel there is no need to modify their lifestyle.

On strategies to promote engagement: It's really about whether we understand individual behavior and what motivates and inspires individuals to take action to improve their health. We have to look beyond just treating the physical medical condition and look at the other dimensions of health, such as mental, social, and financial health and how to motivate patients. We are addressing other dimensions of health to get at physical health through innovative, engaging outreach programs and other tools.

I believe in group intervention. The cliché “misery loves company” is true, and that is why group therapy works. Group functions work because of our competitive nature. Internally we always want to be at our best. And, if we saw that we weren't doing well against our peers, whether it is physicians or patients, it does get attention. But also there is that support structure to know that "I'm not alone. Someone else is going through this and this works for them, and maybe I should give it a go."

Don Beckstead, MD
Program Director
Altoona (PA.) Family Physicians

Why is it difficult? There are probably two major reasons. One is that some of the patients don't think that it is their primary responsibility. They feel it is my responsibility to “make them healthy.” That is just some, not everybody. There is a second contingent of people who are either too busy, too tired, too unmotivated or whatever it would be in order to follow directions.

It's not just insurance companies and the government, but the hospital systems in general that are being pressured on these quality measures, and they then are putting the pressure on the doctors and the medical staff to do all of these things. Of course we are trying to pass that along to the patients, because if they aren't willing to pitch in and help out, we aren't going to get the numbers we are all looking for.

We participate in a quality improvement initiative called Improving Performance in Practice. It is a collaborative of all of the family medicine residency programs in Pennsylvania.

The quality has improved. If you look at the percentage of our patients, the diabetics who had the hemoglobin A1Cs done in the past six months, those numbers are all better. The sad part is they are not getting better quickly or dramatically. But at least we are seeing statistically significant positive results, so it's enough of a reason to keep us going.